173 Maternal and Perinatal outcome among the booked and unbooked pregn - PDF document

173 Maternal and Perinatal outcome among the booked and unbooked pregnancies from catchments area of BP Koirala Institute of Health , Lama GJ, Banerjee B, Paudel LS, PK PokharelDepartment of Obstetrics & Gynecology, Community Medicine, B.P.Koirala Institute of Health Sciences, Dharan, Nepal Abstract: Objectives: To examine the differences in maternal and pe Kathmandu University Medical Journal (2007), Vol. 5, No. 2, Issue 18, 173-176 174 deaths occur either during or shortly after delivery, yet many women do not receive the essential health care they need during these periods. The percentage of women, who seek antenatal care at least once, is 65 percent in Asia. In Nepal, only 10% of women receive proper antenatal care. The reason for not utilizing existing facilities is also a concern, as many unbooked cases are seen with more complications.The Institute commands huge human resource as in it employs a great deal of health professionals and commits in its mission statement to change the health status in the region. This level of commitment to improvement from such a prestigious Institution needs to be matched by concerns for equity and access. Maternal health care needs to be addressed from grassroots levels to tertiary care centre provisions, in an integrated approach. With this impression, this study was planned to explore the differences in maternal and perinatal outcomes among the booked and unbooked cases, so that hospital policy will have the opportunity to improve its extension to community-based health Institutions. The mission success or otherwise of community oriented and population based institutions is yet to be seen. It will be judged on how its satellite peripheral health institutions can improve the service provision demonstrating evidences in outcome. The objectives of this study is to find out the differences of maternal and fetal outcome between booked and unbooked mothers and to elucidate their perception & reason for under utilization of services targeted for them. Material and Methods Our study population comprised of 2228 pregnant mothers, booked and unbooked, attending obstetric emergency of B.P.Koirala Institute of Health Sciences, Department of Obstetrics and Gynecology, for delivery; and the mothers who delivered at home and brought to the hospital for emergency obstetric care from January to December 2005. These mothers were followed by the investigators till discharge. The Study population was divided into two groups; group A-Booked Mothers (n=1172), and Unbooked (n=1056). Booked Patients were those who had attended Antenatal Clinic in our Institute at least once and the unbooked group included the patients who had not attended the antenatal care clinic. A focus group discussion was organized for four groups of women, doing stratified random sampling, consisting of eight women in each group, before their discharge from the hospital. The groups were made homogenous in terms of educational background and social class prior to discussion. Issues discussed with mothers in the Focus Group included: what factors encouraged the booked mothers to avail of antenatal services and the reasons which delayed the unbooked patients to utilize the available services for them. ANOVA is applied to compare the means; Chi-Square and Fisher's Exact Tests were used for assessing the statistical significance of the association between the variables. Results Age (Table 1); distance from the hospital and parity were significant factors in the differences between the groups. Primagravidas accounted for more of the unbooked mothers (100%) compared to the booked group (96.6%). There was significant difference between the period of gestation at which they present to the hospital among both the groups ( 0.0001). Among the unbooked, 81.4% of the mothers did not know the period of gestation. That is most of the women conceived during lactational or depo provera induced amenorrhea. 16out of 1056 unbooked mothers underwent obstetrical hysterectomy due to uncontrolled post partum hemorrhage, uterine atony, following prolonged obstructed labour and sepsis. The maternal mortality for unbooked patients was 16 out of 1056 and none among the booked. Perinatal mortality is 3 times less in booked patients. Higher perinatal deaths are associated with home deliveries. (Table No. II) Unbooked mothers had a higher proportion of maternal intensive care unit admissions and perinatal deaths compared with the booked. (Table No. II) 175 Table 1: Mean age and baby weight among booked and unbooked cases: Variables Booked (n=1172) Unbooked (n=1056) P Value Age of mother 24.57±4.17 23.81±4.92 .005 Baby weight (Mean±SD) 3.03±0.56 2.79±0.59 .0001 Table 2: Maternal, perinatal and neonatal outcome among booked & unbooked mothers Variables Booked % (n=1172) Unbooked% (n=1056) P value Maternal outcome Good 100.00 96.6 1.9 1.5 Perinatal Outcome Good 97.3 2.7 80.3 8.7 11.0 Neonatal Outcome Good 99.3 0.7 95.5 0.4 4.2 Table 3: Relation of Booked & Unbooked cases to different variables (n=2228) Variables Booked (%) Unbooked (%) P Value Distance 72.4 27.6 47.3 52.7 .0001 Primigravida Multigravida Grandmultigravida 46.8 48.8 4.4 59.7 34.1 6.4 .002 Term Post term Unknown POG 84.6 6.8 5.8 2.7 57.6 12.1 17.0 13.3 .0001 Stage of labour Active 70.0 30.0 58.7 41.3 Mode of Delivery Normal LSCS Instrumental Cesarean Hysterectomy 65.5 31.7 2.7 55.9 39.8 2.7 1.6 POG: Period of Gestation, LSCS: Lower segment caesarian section 176 Discussion Educating the community about the benefits of receiving regular antenatal care, at grass roots level may have a significant impact on improving pregnancy outcomes.Currently, the Level of Care is diluted and many institutions at the periphery are not utilized at all. Bed management systems need to be developed and reviewed to optimise bed use. Focus group discussions revealed that filling the knowledge gap alone will not sufficiently address the problem of maternal death. Targeted, integrated, patient friendly, affordable, accessible services need to be delivered in an equitable manner. Increased public awareness of the need for and availability of these services would improve the outcomes for many women and children. Antenatal care and its importance can be implemented through general and health education, improved public health status, developing infrastructure, transport and communication facilities. Respondents from both groups of mothers held that maternal health care delivery should be of three different degrees. Primary care should involve maternity homes and centers which should be staffed by trained midwives supervised by obstetricians. Secondary care should involve hospitals directed by obstetricians and capable of providing emergency services. Tertiary care should be available in University teaching hospitals promoting health care work training and research. Our research indicates that mothers in Nepal know about the importance of health care during pregnancy, but are currently not able to access it due to powerful circumstances beyond their control. In our study we found that distance from hospital too had an affect on outcomes where even booked mothers reached hospital in late second stage of labour. We contend that planning to build bigger hospitals with sophisticated technology alone will not improve the maternal and fetal outcome. Rather, primary and secondary hospitals, built for a targeted population and supporting trained staff to work in primary facilities, may have an impact in reducing these preventable tragedies in Nepal. Government and Non Governmental Organisations as a priority in millennium development goals highlighted maternal healthcare. This qualitative in depth focus group discussion with affected women revealed their rationale for not utilizing the minimum services available to them, though they need it the most. The affected populations unveil the area to be strengthened, if maternal and child healthcare is to be available to them. Distance from health services, hills and mountains, efficient transport to be organized High Cost(direct fees as well as the cost of transportation, drugs and supplies) subsidized Domestic activities restricted during pregnancy. Women should be given decision-making power within the family. Hospital personnel need to be educated to be more clients friendly. ConclusionBooked pregnancies had better maternal and perinatal outcomes .Focus group discussion and results elucidated that services utilization can be improved, fairly equipping peripheral health institutions. 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